Australian Emergency

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AUSTRALIAN EMERGENCY

MANUALS SERIES

PART III

Emergency Management Practice

Volume 1Service Provision

Manual 2

DISASTER MEDICINE

Health and Medical Aspects of Disasters

Second Edition

EMERGENCY MANAGEMENT AUSTRALIA


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Commonwealth of Australia 1999First edition 1995Second edition 1999

ISBN 0 642 47374 9

Edited and published by Emergency Management Australia

Typeset by Director Defence Publishing Service, Department of Defence

Printed in Australia by

INFORMATION ON THE AUSTRALIAN EMERGENCYMANUALS SERIES


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The first publication in the original AEM Series of mainly skills reference manualswas produced in 1989. In August 1996, on advice from the National EmergencyManagement Principles and Practice Advisory Group, EMA agreed to expand theAEM Series to include a more comprehensive range of emergency managementprinciples and practice reference publications. The Series is now structured in five

parts as set out below.

Parts I to III are issued as bound booklets to State and Territory emergencymanagement organisations and appropriate government departments for furtherdissemination to approved users including local government. Parts IV and V (skillsand training management topics) are issued in loose-leaf (amendable) form to allrelevant State agencies through each State and Territory Emergency Service whomaintain State distribution/amendment registers. All private and commercialenquiries are referred to EMA as noted at the end of the Foreword on page vii.

AUSTRALIAN EMERGENCY MANUALS SERIES STRUCTURE AND CONTENTPublishing

StatusDec 99PART I THE FUNDAMENTALSManual 1 Emergency Management Concepts and Principles (3rd edn) A/RManual 2 Australian Emergency Management Arrangements (6th edn) U/RManual 3 Australian Emergency Management Glossary AManual 4 Emergency Management Terms Thesaurus A

PART II APPROACHES TO EMERGENCY MANAGEMENTVolume 1Risk Management

Manual 1 Emergency Risk Management DVolume 2Risk Evaluation

Titles to be advised (covering PPRR) PVolume 3Implementation of Emergency Management Plans

Titles to be advised PPART III EMERGENCY MANAGEMENT PRACTICE

Volume 1Service Provision

Manual 1 Emergency Catering AManual 2 Disaster Medicine A/RManual 3 Disaster Recovery A/R

Volume 2Specific IssuesManual 1 Evacuation Planning AManual 2 Safe and Healthy Mass Gatherings AManual Health Aspects of CBR Hazards DManual Civil Defence DManual Community Emergency Planning (3rd edn) A/RManual Urban Search and Rescue (Management) D

Volume 3GuidelinesGuide 1 Multi-Agency Incident Management AGuide 2 Community and Personal Support Services AGuide 3 Managing the Floodplain A

Guide 4 Flood Preparedness AGuide 5 Flood Warning AGuide 6 Flood Response AGuide 7 Community Information Gathering DGuide Disaster Victim Identification U/R

PART IV SKILLS FOR EMERGENCY SERVICES PERSONNELManual 1 Storm Damage Operations (2nd edn) AManual 2 Operations Centre Management AManual 3 Leadership AManual 4 Land Search Operations (2nd ednAmdt 1) AManual 5 Road Accident Rescue (2nd edn) AManual 6 General Rescue (4th ednformerly Disaster Rescue) AManual 7 Map Reading and Navigation (Amdt 1) AManual 8 Four-Wheel-Drive Vehicle Operation (Amdt 1) AManual 9 Communications (2nd edn) A

Manual 10 Flood Rescue Boat Operation (2nd edn) AManual 11 Vertical Rescue (2nd edn) A/R


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PART V THE MANAGEMENT OF TRAININGManual 1 Small Group Training Management (2nd edn) AManual 2 Exercise Management D

Key to status: A = Available; A/R = original version Available/under Review; D = under Development; P=

Planned; R = under Review/Revision; U/R = Unavailable/under Review


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FOREWORD

The purpose of this Manual is to provide a basic reference for health and medical

professionals in disastermedicine. It is intended for use in education, training andplanning by all health personnel.

In this context, the terminology health and medical personnel is used to includepersonnel providing first aid, ambulance, medical doctor, nursing, mental health,public health, scientific and other associated expertise and involvement.

This Manual has been reviewed by a national consultative committee (NCC),representative of health professionals, learned bodies, States and Territories, andselected Commonwealth organisations.

The NCC was initiated by the Australian Medical Disaster Coordination Group(AMDCG) of the Australian Health Ministers Advisory Council and is sponsored byEmergency Management Australia, Department of Defence.

Obviously situations change and new policy procedure is regularly being developed.Thus, the Manual will be revised and updated by a NCC every four years.

Proposed changes to the document should be forwarded to the Director General,Emergency Management Australia, at the address shown below, through therelevant State/Territory emergency management organisation.

Duplication may occur in some areas, with the aim of permitting the user togain the desired information from individual or multiple chapter referenceswithout having to scan the entire Manual. It is isued in bound and loose-leafformats to meet the varying needs of users.

The use of trade names in this Manual is not intended to be restrictive, preferential orpromotional, rather, trade names are used where descriptive clarity is required.

This publication is provided free of charge to approved Australian organisationswhich may obtain copies from the Counter Disaster Officer/Unit located in eachState/Territory health department. A contact address appears at the back of the

Manual. Limited free copies for relevant (non-health) emergency managementagencies are issued through each State/Territory emergency managementorganisation.

Manuals may be supplied to other Australian or overseas requesters upon paymentof cost recovery charges. Consideration is given to requests from developingcountries for copies without charges.

Overseas enquiries (for free copies) and all those regarding purchase of this Manualshould be sent to the Director-General, Emergency Management Australia,PO Box 1020, DICKSON ACT 2602, AUSTRALIA, (facsimile +61 (0)2 6257 7665,

Email: [email protected]).


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CONTENTS

Page

INFORMATION ON THE AUSTRALIAN EMERGENCY MANUALS SERIES III

FOREWORD VPREFACE XXI

INTRODUCTION XXIII

SECTION 1OVERVIEW OF DISASTER MEDICINE

CHAPTER 1 OVERVIEW

INTRODUCTION 1DISASTER MANAGEMENT AND PLANNING 1DISASTER MEDICINE PRACTICE 1

DISASTER MEDICINE RESOURCES 1DISASTER MEDICINEOTHER CONSIDERATIONS 1

SECTION 2DISASTER MANAGEMENT AND PLANNING

CHAPTER 2 EMERGENCIES AND DISASTERS: KEY MANAGEMENTCONCEPTS AND ARRANGEMENTS

INTRODUCTION 5EMERGENCIES AND DISASTERS 5

Definitions 5Hazards 5

IMPACT OF DISASTERS ON AUSTRALIA 6EMERGENCY MANAGEMENT CONCEPTS 6

The All Agencies (or Integrated) Approach 6The Comprehensive Approach 7All Hazards Approach 7The Prepared Community 7Emergency Risk Management 7

COMMAND, CONTROL AND COORDINATION 8EMERGENCY AND DISASTER MANAGEMENT

ARRANGEMENTS 8

Integral Elements 8KEY EMERGENCY MANAGEMENT AUTHORITIES 9National 9Commonwealth 9State and Territory 9Local Government 10Other Organisations and Individuals 10

DISASTER MEDICINE AND HEALTH POLICYMAKING 10EMERGENCY MANAGEMENT OPERATIONAL AGENCIES 10

Commonwealth 10Commonwealth Assistance 10

State and Territory 11SUMMARY 12


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REFERENCES 12

CHAPTER 3 PLANNING

INTRODUCTION 13WHY PLAN? 13

PLANNING MANAGEMENT AND RESPONSIBILITIES 13HIERARCHY OF PLANS 13EMERGENCY AND DISASTER PLANNING 14THE PLANNING PROCESS 14CONDUCT RISK ASSESSMENT 17

Hazard Analysis 18Vulnerability Analysis 18Disaster Epidemiology 19Implications for Health Planners 19

HEALTH RESPONSE PLANS 20SPECIAL CONSIDERATIONS IN HEALTH RESPONSE

PLANNING 20Time Delay to Resuscitation 20Time Delay to Surgery 21Initial Phase 21Follow-up Phase 21Care for People with Disabilities 21Detainees in Custodial/Correctional Institutions 22Remote Area Planning 22Major Events 22Common Difficulties in Disaster Response Planning 22

SUMMARY 23REFERENCES 23Annex:A. Disasters and their Health Effects

SECTION 3DISASTER MANAGEMENT PRACTICE

CHAPTER 4 PUBLIC HEALTHPREVENTION AND MITIGATION

INTRODUCTION 29INTERSECTORAL APPROACH 29MEASURES 29MITIGATION STRATEGIES 29SUMMARY 30REFERENCE 30

CHAPTER 5 HEALTH RESPONSE AND

INTRODUCTION 31MANAGEMENT STRUCTURE 31COMMAND, CONTROL, COORDINATION AND

COMMUNICATION 31

Introduction 31Command 31


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Control 32Coordination 32Establishing Medical Control 32Communication 32

INTELLIGENCE 33

COMMUNICATIONS 33Communications Network 33

STATE LEVEL DISASTER MANAGEMENT 34REGIONAL LEVEL DISASTER MANAGEMENT 34HOSPITAL 34DISASTER SITE MANAGEMENT 34MEDICAL INCIDENT MANAGEMENT 34DOCUMENTATION 35SITE ARRANGEMENTS 35SITE MANAGEMENT AND PERSONNEL 36SUMMARY 37

Annexes:A. Communications Network (South Australian example)B. Site Management and Personnel (South Australian example)C. Site Personnel

CHAPTER 6 TRIAGE

INTRODUCTION 49OBJECTIVE 49TIMING 49PERSONNEL 49

PRIORITIES 50THE EXPECTANT CATEGORY 50THE PROCESS OF TRIAGE 50TRIAGE AT THE SITE 51TRIAGE AT THE HOSPITAL 52PRACTISING TRIAGE 52SUMMARY 52REFERENCES 52

CHAPTER 7 CLINICAL MANAGEMENT

INTRODUCTION 53OBJECTIVE 53RESUSCITATION 53AIRWAY MANAGEMENT 53

Equipment 54Muscle Relaxants 54Sedatives 54

ANALGESIA 54Immobilise Fractures and Cover Burns 54

BURNS 54Burns Resuscitation 55

CARBON MONOXIDE POISONING 55Exposure 55


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HYPOTHERMIA 55CRUSH INJURY 55WOUNDS 55FRACTURES/DISLOCATIONS 56CHILDREN 56

RADIATION INJURY 56Ionising Radiation Exposure 56General Procedure 56

CHEMICAL INJURY 56Management Priorities 57

SUMMARY 57

CHAPTER 8 TRANSPORT

INTRODUCTION 59WHY? 59

Caution Prior to Discharge 59WHEN? 60

Injury Priorities 60WHERE? 60

Patient Distribution/Regulation 60HOW? 61

Coordination 61Modes of Transport 61Road Ambulances 61Helicopters 62Fixed-Wing Aircraft 62

Pre-flight Patient Stabilisation 62Clinical Effects of Flight 62GENERAL 62

Basic Requirements 62Improvisation 63Infectious Diseases 63Hazardous Materials 63Personnel 63Documentation 64Deceased Persons 64

SUMMARY 64

REFERENCES 64Annexes:A. TriagePatient Distribution Urban ModelB. TriagePatient Distribution Rural Model

CHAPTER 9 HOSPITAL DISASTER PLANNING

INTRODUCTION 69HOSPITAL PLANNING NEEDS 69COPING WITH DISASTER 69HOSPITAL ROLES IN DISASTER 69

FIELD MEDICAL TEAMS 70TRANSPORT OF TEAMS AND EQUIPMENT 70


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HOSPITAL RESPONSE TIME 70Plan Format 70

PLANNING CONSIDERATIONS 71TRAINING 73REVIEW AND MAINTENANCE 74

PRIVATE HOSPITALS 74Disaster Role 74Disaster Plans 74

SUMMARY 74REFERENCES 75

Annexes:A. Guidelines for a Hospital Disaster Planning CommitteeB. Facility/Hospital Disaster Plan Check List

(New South Wales Health example)C. Hospital Control Centre Arrangements

D. How to Conduct a Simple Hospital Disaster Exercise

CHAPTER 10 PUBLIC HEALTHRESPONSE

INTRODUCTION 99INFORMATION 99

Immediate Assessment 99Detailed Assessment 100Relief Priorities 100

MANAGEMENT 101WATER 101

Quality 101

Supply 101Sources 102Water Treatment 103Storage of Treated Water 103Transport of Treated Water 103Other Hazards Associated with Water Supplies 103

SHELTER 104Urgency and Resource Factors 104Use of Home Sites 104Site Identification 104Emergency Shelter 104

FOOD AND RELATED CONCERNS 104Food Management 105Food Poisoning 105Emergency Food Production/Preparation 105Special Food Surveillance 106Supervision of Food-Handlers 106Mass Feeding 107Examination of Damaged Food 107Examination of Donated Food 108Personal Hygiene 108

Disinfection 109SANITATION 109


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Emergency Washing and Toilet Facilities 109Use of Existing Septic Tank Systems 110Disposal of Sullage Wastes 110Drug Disposal 110Refuse Disposal 111

Hazardous Waste Disposal 112Criteria for Identifying Hazardous Waste 113Disposal of Dead Animals 114Vermin and Vector Control 115

INFECTIOUS DISEASES 118Introduction 118Public Perception of Disease Risk 118Risk Factors 118Transmission Methods 118Mitigating Transmission 119Control Principles 119

Specific Control Measures 119SUMMARY 120REFERENCES 120

Annexes:A. Water TreatmentB. Emergency Accommodation Venues Information Check listC. CampsitesD. Mass Feeding CentresE. Disinfection Dilution FactorsF. Construction of Temporary Toilet, Shower and Laundry

FacilitiesG. Recommended Number of Toilets Showers and Laundry

FacilitiesH. IncinerationI. Disposal and Destruction of AnimalsJ. Infectious Diseases of Public Health ImportanceK. Infectious Diseases Outbreak Reporting Form

CHAPTER 11 MENTAL HEALTH

INTRODUCTION 151Preparation and Training for Disaster Response 151Warning and Threat 151Disaster Impact 151Immediate Post-Disaster Period 151

ACUTE PHASE INTERVENTIONS 152Support for Affected Populations 152Information Provision 152Emergency Support and Triage 152Bereaved People 152Disaster-Affected People Who Have Been Psychologically

Traumatised 153

Those Who Have Lost Home, Community or Place ofBeing 153


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Emergency Workers and Rescuers 153LONGER-TERM INTERVENTIONS 153GROUPS WITH PARTICULAR NEEDS 155

Children and Adolescents 155Refugee and Migrant Populations 155

Older People 155SUMMARY 156REFERENCE 157

CHAPTER 12 POSTDISASTER ACTIVITIES

INTRODUCTION 159EQUIPMENT 159

Replace and Repair 159Equipment Requests 159

DEBRIEFING 159REVIEW OF PLANS 159DOCUMENTATION 159EDUCATION AND TRAINING 160REHABILITATION 160RESTORATION OF NORMAL FUNCTIONS 160

Minimising Physical and Emotional Health Impacts 160RIGHTS OF ACCESS 160SAFETY ASSESSMENT 160SENSITIVITY AND CONSULTATION 161EMOTIONAL IMPACT 161

THE RECOVERY PROCESS 161Self-Determination 161SPECIFIC RESTORATION REQUIREMENTS 161FLEXIBILITY 161SUMMARY 162REFERENCES 162

SECTION 4DISASTER MEDICINE RESOURCES

CHAPTER 13 OTHER RESOURCES

INTRODUCTION 165PERSONNEL 165

Local Practitioners 165First Aid Organisations 165Australian Defence Force 166Royal Flying Doctor Service 166

BLOOD TRANSFUSION SERVICES 166Other 166

REMOTE AREA ASSETS 166Royal Flying Doctor Service 166RFDS Medical Chests 166Visiting Medical Services 167HF Radio Network 167


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Northern Territory Aerial Medical Service 167Commercial Rescue and Retrieval Organisations 167Bush Nursing Posts 167Mining and Industrial Sites 168

SHIPS 168

Merchant Navy 168Royal Australian Navy 168

RAILWAYS 168SUMMARY 168REFERENCE 169Annex:A. Australian Defence Force Medical and Health Assets and

Royal Flying Doctor Service Bases

CHAPTER 14 MEDICAL SUPPLIES AND EQUIPMENT

INTRODUCTION 173MEDICAL SUPPLIES AND STORES 173

Potential Problems 173Optimal Care 174Supply Planning 174

PHARMACEUTICAL AND EQUIPMENT LISTS 174Australian Medical Disaster Coordination Group

Pharmaceutical and Medical Equipment List forDisasters 174

World Health Organization (WHO)EmergencyHealth Kit 175

Red Cross Emergency Set 175MEDICAL EQUIPMENT 175Familiarisation 176Maintenance 176Suitability 176

MEDICAL EQUIPMENT SETS 177General Medical 177Airway and Respiratory Support 177Haemorrhage and Circulatory Support 177General and Miscellaneous 177Emergency Drugs 177

Other Kits 177Major Equipment and Supplies 178Other Equipment 178

BLOOD (SUPPLY AND TRANSPORT) 178IMPROVISATION 179SUMMARY 179REFERENCES 179Annexes:A. Airway and Respiratory SupportB. Haemorrhage Control and CirculatorySupportC. General and Miscellaneous Equipment

D. Drug Box


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CHAPTER 15 PERSONAL EQUIPMENT AND IDENTIFICATION

INTRODUCTION 189PERSONAL EQUIPMENT 189

Helmet 189Eye Protection 189Respiratory Protection 189Overalls 190Footwear 190Gloves 190Environmental Factors 190Comfort Kit 191

PERSONAL IDENTIFICATION 191REMOTE AREA AND OVERSEAS RESPONSES 191SUMMARY 191Annex:

A. Recommended Personnel Equipment for Disaster MedicalAssistance Team Members

SECTION 5DISASTER MEDICINEOTHER CONSIDERATIONS

CHAPTER 16 MASS GATHERINGS

INTRODUCTION 197THE NEED TO PLAN 197APPROVAL FOR THE EVENT 197LEGAL ISSUES 198

VENUE 198General 198Hazards 199Access and Egress of Health and Emergency Services 199Crowd Movement 200

SPECTATORS 201PUBLIC HEALTH 202MEDICAL CARE 202

General 202Facilities 203Ambulances 203Logistics 203

EMERGENCY RESPONSE PLANS 203Event Cancellation or Postponement 204

SPECIAL EVENTS 204DEFENCE ASSISTANCE 205SUMMARY 205REFERENCES 206

CHAPTER 17 CHEMICAL, BIOLOGICAL AND RADIOLOGICALINCIDENTS

INTRODUCTION 207CHEMICAL AGENT TYPES, EFFECTS AND TREATMENT 208


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Background 208Routes of Absorption 208Effectiveness 208

CHEMICALNERVE AGENTS 209Properties 209

Actions 209Effects 209Treatment 210

CHEMICALVESICANT (BLISTER) AGENTS 210Properties 210Actions 211Effects 211Treatment 211

CHEMICALLUNG-DAMAGING (CHOKING) AGENTS 212Properties 212Actions 212

Effects 212Treatment 212

CHEMICALCYANIDE (BLOOD) AGENTS 212Properties 212Actions 213Effects 213Treatment 213

OTHER CHEMICAL AGENTS 213CHEMICAL AGENT DETECTION 214CHEMICAL GENERAL/MASS CASUALTY MANAGEMENT 214BIOLOGICAL AGENT TYPES, EFFECTS AND

TREATMENT 215Background 215Routes of Absorption 215Agent Characteristics 215

BIOLOGICALBACTERIA 216Anthrax 216Plague 217Tularemia 217

BIOLOGICALVIRUSES 218Smallpox 218

Venezuelan Equine Encephalitis 218CongoCrimean Haemorrhagic Fever (CCHF) 218BIOLOGICALRICKETTSIAE 219

Q Fever 219BIOLOGICALTOXINS 219

Botulism 219Staphylococcal Enterotoxin B 220Ricin 220

BIOLOGICAL AGENT DETECTION 220BIOLOGICAL GENERAL/MASS CASUALTY

MANAGEMENT 221

RADIOLOGICAL EFFECTS AND TREATMENTS 222Background 222


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Agent Characteristics and Effectiveness 223Routes of Absorption 223Actions and Clinical Effects 224Acute Radiation Sickness 224Haemopoietic Syndrome 225

Gastrointestinal Syndrome 225Neurovascular Syndrome 225Diagnosis 225Chronic Effects 226Treatment 226

RADIOLOGICAL AGENT DETECTION 226RADIOLOGICAL GENERAL/MASS CASUALTY

MANAGEMENT 227DECONTAMINATION (ALL AGENTS) 227

ChemicalNerve and Vesicant 228Other Chemical 228

Biological 228Radiological 229

PERSONAL PROTECTION 229General/Chemical 229Biological 229Radiological 230

COLLECTIVE PROTECTION 230Chemical 230Biological 230Radiological 230

MEDICAL RESPONSE TO CHEMICAL, BIOLOGICAL ANDRADIOLOGICAL INCIDENTS 231Prevention and Protection 231Detection and Identification 232Decontamination 232Triage 232Treatment and Evacuation 233


Special Note 235Annexes:

A. Glossary of Terms for Chapter SeventeenB. Abbreviations AND ACRONYMs forChapter 17

CHAPTER 18 LEGAL, OCCUPATIONAL HEALTH AND SAFETY AND

FINANCIAL ISSUES

LEGAL ASPECTS 241Legislation 241

OCCUPATIONAL HEALTH AND SAFETYCONSIDERATIONS 241Training 241

Personal Protective Clothing 242Other Protective Equipment 242


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Substance Precautions 242Disease Transmission 243Environmental Control 243Personnel Movement Practices 243Unfamiliar Transport and Machinery 244

Climatic Protection 244Briefing of Responders 244Work Practices 244Health of Respondents 244

FINANCIAL ASPECTS 245Financial Administration 245Commonwealth Financial Responsibilities 245

REFERENCE 245

CHAPTER 19 DOCUMENTATION

INTRODUCTION 247Rationale for Documentation 247

TRIAGE TAGS 247PATIENT CARE 248

Patient Movement/Registration Form 248Medico-Legal 248

OTHER DOCUMENTATION 248Ambulance Officer Patient Report Form 248Hospital Documents 248

QUALITY MANAGEMENT 248CORONIAL ASPECTS 249

RESEARCH 249SUMMARY 249Annex:A. Example of a Triage Tag

CHAPTER 20 TRAINING AND EXERCISES

INTRODUCTION 253Aim 253

Disaster Medicine 253Policy Considerations 253Disaster Management Education 253Skills Training 253TRAINING MANAGEMENT (GENERAL

CONSIDERATIONS) 254Skills Acquisition and Maintenance 254Coordination Training 254Specialised Training 255Validation of Training 255Efficiency 255Effectiveness 255

TRAINING EXERCISES 255

Introduction 255Exercise Planning 256


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Policy 256Detailed Plan 256Post-Exercise Activities 257


Annex:A. Exercise Planning model

CHAPTER 21 CULTURAL AND SPECIAL NEEDS CONSIDERATIONS

INTRODUCTION 261CULTURAL REQUIREMENTS 261SKILLS DEVELOPMENT 261

Key Skills 261Planning and Training 262

OTHER SPECIAL NEEDS 263

Disability 263Dietary 263Medical Requirements 264


CHAPTER 22 THE MANAGEMENT OF DECEASED

INTRODUCTION 265MANAGEMENT AT THE SCENE 265MOVEMENT, STORAGE AND DISPOSAL 266

Movement 266Storage and Disposal 266

PSYCHOLOGICAL EFFECTS OF EXPOSURE TODEATH AND HUMAN REMAINS 267Survivors, Injured and Witnesses 267Disaster Workers 268

MANAGEMENT AND PSYCHOLOGICAL CARE 269Survivors and Witnesses 269Disaster Workers 269

SUMMARY 270REFERENCE 270

CHAPTER 23 PUBLIC RELATIONS

INTRODUCTION 271RECEPTION OF RELATIVES 271

Relatives Reception Area 271Casualty Lists 271Releasing Patients 272Identification 272

VOLUNTEER MANAGEMENT 272Planning 272Reception and Deployment 272

VERY IMPORTANT PERSONS 272SUMMARY 272


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REFERENCES 273

CHAPTER 24 MEDIA

MANAGING THE MEDIA 275Developed World 275

Developing World 275VALUE OF THE MEDIA 275

Benefits 275Media Relations 276

MUTUAL COOPERATION AND PLANNING 276Media Liaison 276Disaster Site Access 278News Conferences 278Conference Guidelines 278At the Hospital 278Requests for Information 279

MEDIA RELEASES 279SUMMARY 279REFERENCES 279

Annex:A. Hospital First Media Release Format and Ambulance

First Media Release

SECTION 6SUPPORTING INFORMATION

GLOSSARYACRONYMS AND ABBREVIATIONSFURTHER READINGLIST OF CONTRIBUTING ORGANISATIONS

MEMBERSHIP OF THE NATIONAL CONSULTATIVE COMMITTEE ON DISASTERMEDICINE


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PREFACE

In recent times much attention has been focused on generic emergencymanagement. This document concentrates on the important aspects of the

preservation of life, the effective management of the injured, and the restoration ofthe general health and well-being of the affected community.

Some years ago sections of the health profession approached the FederalGovernment for assistance with the training of medical practitioners, particularly inrural and remote areas, to handle mass casualty situations, where resources areoften overwhelmed.

Following discussion between Emergency Management Australia and the thenCommonwealth Department of Health and Family Services, a special working partywas set up to look at a number of options to improve the nations health and medical

capability, to assist in such circumstances. The Working Party comprised of selectedexperts from States and Territories and the Commonwealth, and a wide range ofrelevant professions.

The original Working Party decided to develop a series of training aids, to be knownas the Australian Disaster Medical Training Package, which were widelydisseminated free of charge, to appropriate organisations throughout the nation, tofacilitate education and training in disaster medicine.

Two video tapes were madeYou Can Make A Difference which was directedspecifically at the medical professions and Disasters are Different especially

produced about Australian disasters and major incidents.

The key component within the Package was the development of this AustralianEmergency ManualDisaster Medicine. This first edition became available inMarch 1995.

The Manual attracted a quite unexpected level of interest and use. Disseminatedwidely, it also received wide national and international acclaim from the World HealthOrganization, and a number of comparable developed nations.

This new edition reflects developments and innovations over the intervening years,

including risk management and assessment. Also new initiatives such as massgathering medicine aspects; chemical, biological and radiation situations; andepidemiology and research, have been added. The experiences arising from the PortArthur Massacre and the Thredbo Landslide have been incorporated.

Many contributors Australia-wide should be thanked for their time and input with thedevelopment of the Manual. A final Draft was circulated to over 150 organisationsand selected individuals with a three month comment period.

The Manual is the core component of the National Disaster Medicine TrainingCourse, held annually at EMAs Australian Emergency Management Institute, and

the derived portable Australian Disaster Medicine Course, for use across the country.


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These initiatives are conducted under the Australian Medical Disaster CoordinationGroup (AMDCG) of the Australian Health Ministers Advisory Council.

The AMDCG comprises representatives from All States and Territories and theCommonwealth including the Department of Defence, the Department of Health and

Aged Care and Emergency Management Australia.

I commend the 1999 Edition of this Manual to all health professionals andemergency managers.

Comments should be addressed to: The Secretary, AMDCG, c/- Counter DisasterUnit, MDP 27, Department of Health and Aged Care, GPO Box 9848, Canberra ACT2601, Australia.

(Dr) DIANA HORVATHCHAIRAUSTRALIAN MEDICAL DISASTER COORDINATION GROUPMAY 1999


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INTRODUCTION

AIM

The aim of this publication is to provide a basic reference for health and medicalprofessionals in disaster medicine.

DEFINITION

Disaster medicine is the prevention, reduction and mitigation of the effects ofdisasters on the health of communities; the provision of appropriate treatment forthose affected; and the restoration of health services and facilities to the pre-disastersituation as soon as possible.

The provision of health and medical care in response to any disaster often involves

mass casualty management. It includes rescue, first aid, casualty clearing,emergency surgical procedures, hospital treatment, mental health and environmentalhealth measures.

Disaster medicine requires a different approach than that for emergency medicineand normal public health management practices, because of the overwhelmingnature of the event and the associated disorder.


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CHAPTER 1

OVERVIEW

INTRODUCTION

1. The Manual provides guidance on managing health aspects of disasters. It isdivided into four sections, each containing a number of chapters, as well assome supporting appendices.

DISASTER MANAGEMENT AND PLANNING

2. This Section includes general disaster management concepts andarrangements, as well as planning concepts and processes. The management

of health effects of disasters must be integrated with other elements ofemergency management. Of particular importance is the requirement toaddress all phases of the disaster management process (prevention,preparedness, response and recovery), as well as to incorporate a total healthresponse, including:

ambulance;

acute medical care;

first aid;

public health; and mental health.

3. Planning concepts and processes include the need to examine hazards, fromthe health perspective, for their likely health implications, including the use ofdisaster epidemiology.

DISASTER MEDICINE PRACTICE

4. This Section incorporates specific arrangements involved in managing health

aspects of disasters. This includes public health, site response, triage, clinicalmanagement, transport, hospitals and mental health. The manual does notinclude specific clinical management of diseases and injuries, as adequatetexts already exist in these areas.

DISASTER MEDICINE RESOURCES

5. This Section looks at specific health resources involved in managing disasters.These range from individual equipment used by medical teams, up to resourcesat a community, State or Commonwealth level.


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DISASTER MEDICINEOTHER CONSIDERATIONS

6. This Section considers a number of areas which, although they may not fallspecifically in the health arrangements, can impact significantly on the health

response to a disaster. These include mass gatherings, the management of thedeceased, cultural considerations, handling the media, and legal and financialconsiderations.

7. Disasters of all types are notable in their ability to not only damage property, butalso to cause pain and suffering on a massive scale. To effectively managesuch events from a health perspective requires not only the clinical skill from anindividual perspective, but also to appreciate the big picture from a truepopulation health perspective.


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CHAPTER 2

EMERGENCIES AND DISASTERS: KEY

MANAGEMENT CONCEPTS AND ARRANGEMENTSINTRODUCTION

1. The purpose of this chapter is to describe Australias emergency and disasterarrangements and the concepts on which they are based.

EMERGENCIES AND DISASTERS

Definitions

2. In disaster management in Australia the terms emergency and disaster areoften used interchangeably. The Australian Emergency Management Glossaryoffers the following definitions:

EmergencyAn event, actual or imminent, which endangers or threatensto endanger life, property or the environment, and which requires asignificant and coordinated response.

DisasterA serious disruption to community life which threatens orcauses death or injury in that community, and damage to property which isbeyond the day-to-day capacity of the prescribed statutory authorities and

which requires special mobilisation and organisation of resources otherthan those normally available to those authorities.

3. This manual covers the requirements for managing health aspects of majorrisks to the well being of the community. These risks have the potential tooverwhelm community and organisational arrangements, and may requireextraordinary responses to be instituted.

Hazards

4. Emergencies and disasters occur when a hazard impacts upon a community

which is vulnerable to that hazard. The magnitude of the event varies accordingto the characteristics of the hazard (such as type and the intensity), vulnerabilitycharacteristics of the community (such as levels of prevention, demographicprofile and preparedness) and their interaction.

5. Emergencies and disasters are usually described by the hazards associatedwith them. Australian communities live with a variety of natural andtechnological hazards. Natural hazards include all those of climatic, geophysicalor biological origin, while technological hazards include those arising fromnuclear/biological/chemical technology, human fault and hostile action.

6. The presence of some major natural hazards, such as cyclones and bushfiresdepends on the season and geographic region, but other types of hazards,


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particularly those made by humans, are less predictable, and could impactalmost anywhere.

IMPACT OF DISASTERS ON AUSTRALIA

7. Australia has experienced a wide range of disasters which have resulted inmultiple deaths, injuries and psychological trauma and significant social,economic and environmental losses. These losses can be reduced by effectivedisaster prevention, preparedness, response and recovery strategies.

8. On average, natural disasters (excluding drought) affect over 500,000Australians every year. In the past 25 years, Australia has experienced, onaverage, a major disaster about once every four years. These have includedCyclone Tracy, Ash Wednesday Bushfires, Newcastle Earthquake, 1994 NSWBushfires, Sydney severe storms including hailstorms (1990, 1991 and 1999),Thredbo Landslide, Cyclone Vance (Exmouth) and major flooding around

Brisbane (1974), Nyngan and Charleville (1990), Adelaide (1992), Benalla(1993) and Townsville and Katherine (1998). Smaller disasters andemergencies have occurred more frequently. Additionally, Australia hasexperienced many major non-natural disasters such as the collapse of theWestgate and Tasman Bridges, the Granville train crash, the Coode Islandfires, the Port Arthur Massacre, interruption to gas supplies in Victoria, andseveral costly oil spills.

9. Tangible losses (ie those that can be expressed in dollar terms) includedamages to buildings and contents, to commerce and industry, toinfrastructure, and to homes, other property and jobs. Total average annuallosses from natural disasters (excluding drought) are estimated to exceed $1.25billion. The intangible losses include injury and death and personal distress. Inthe last 25 years, natural disasters have caused over 500 deaths and 6000injuries in Australia. Disasters have in some way affected, over 12.5 millionpeople, in aggregate, over this period.

10. The consequential impacts of these events are that businesses collapse, jobsare lost, tourism suffers, insurance premiums rise, and local, regional andnational economies suffer.

11. Most communities are unable to meet the costs of disasters. With costsescalating, the capacity of communities to cope is even more likely to beoverwhelmed by disasters. Disasters of substantial magnitude are not limited tolocal or regional impacts. The whole country is affected and providesassistance and support to those directly impacted.

EMERGENCY MANAGEMENT CONCEPTS

12. Australian emergency and disaster management arrangements are based onfour well-established concepts:

The All Agencies (or Integrated) Approach

The Comprehensive Approach


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The All Hazards Approach

The Prepared Community

13. Emergency Risk Management is a relatively new concept which is readily

gaining acceptance among the Australian disaster management community.


14. Arrangements for dealing with disasters involve active partnerships amongCommonwealth, State and Territory and local levels of government, statutoryauthorities, private, voluntary and community organisations, and individuals.The All Agencies Approach ensures that all the agencies likely to be involved inany disaster or emergency work together smoothly in the implementation ofemergency management arrangements.


15. The comprehensive approach to disaster management embraces strategies inprevention, preparedness, response and recovery (PPRR). PPRR are aspectsof disaster management, not sequential phases.

PreventionRegulatory and physical measures to ensure thatemergencies are prevented, or their effects mitigated.

PreparednessArrangements to ensure that, should a disaster occur, allthose resources and services which may be needed to cope with the

effects, can be rapidly mobilised and deployed. ResponseActions taken in anticipation of, during and immediately after

impact to ensure that its effects are minimised and that people are givenimmediate relief and support.

RecoveryThe coordinated process of supporting disaster-affectedcommunities in reconstructing their physical infrastructure and restorationof emotional, social, economic and physical well-being.

All Hazards Approach

16. Different types of hazards can cause similar problems for a community.Therefore it is desirable to establish a single set of management arrangementscapable of encompassing all hazards. The All Hazards Approach requires theidentification of all hazards likely to be faced by a community followed by theapplication of simple arrangements which, to the maximum extent possible,cater for all events. Many hazards, however, will also require specificprevention, preparedness, response and recovery measures.


17. Australias disaster management arrangements focus on preparingcommunities for emergencies and disasters. A prepared community is one


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which has developed effective emergency and disaster managementarrangements at the local level, resulting in:

an alert, informed and active community which supports its voluntaryorganisations;

an active and involved local government; and

agreed and coordinated arrangement for prevention, preparedness,response and recovery.

Emergency Risk Management

18. The release of the Australian/New Zealand Standard on Risk Management(AS/NZS 4360:1995) has prompted emergency managers to examine theapplication of the risk management approach to the management of risks tocommunities. The Standard defines risk management as the systematicapplication of management policies, procedures and practices to the tasks ofidentifying, analysing, evaluating, treating and monitoring risk. (AS/NZS 4360)In the emergency risk management context, hazards can be consideredsources of risk, the community as the element at risk, and risk as theinteractions between them and the environment. Hence, emergencymanagement can be defined as the range of measures to manage the risksbetween the community and its environment. Emergency risk management willassist communities to minimise their risk through the preparation ofcomprehensive plans of prevention, preparedness, response and recoverystrategies.

COMMAND, CONTROL AND COORDINATION

19. Emergency management structures and plans prescribe the command, controland coordination arrangements to apply during multi-service operations. Thesearrangements are as follows:

CommandThe direction of members and resources of an organisationin the performance of the organisations role and tasks. Authority tocommand is established in legislation or by agreement with anorganisation. Command relates to organisation and operates vertically

within an organisation. ControlThe overall direction of emergency management activities in an

emergency situation. Authority for control is established in legislation or inan emergency plan, and carries with it the responsibility for tasking andcoordinating other organisations in accordance with the needs of thesituation. Control relates to situations and operates horizontally acrossorganisations.

CoordinationThe bringing together of organisations and elements toensure an effective response, primarily concerned with systematicacquisition and application of resources (organisation, personnel, andequipment) in accordance with the requirements imposed by the threat orimpact of an emergency. Coordination relates primarily to resources, and


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operates, vertically within an organisation, as a function of the authority tocommand, and horizontally, across organisations, as a function of theauthority to control.

EMERGENCY AND DISASTER MANAGEMENT ARRANGEMENTS

20. In broad terms, emergency management is a range of measures to managerisks to communities and the environment. More specifically, emergencymanagement is the organisation and management of resources for dealing withall aspects of emergencies and disasters. It involves the plans, structures andarrangements which are established to bring together the normal endeavours ofgovernment, voluntary and private agencies in a comprehensive andcoordinated way to deal with the whole spectrum of emergency needs includingprevention, preparedness response and recovery.

Integral Elements

21. The following elements are considered integral parts of emergency and disastermanagement:

An alert, informed and prepared community.

The identification and assessment of the risks that the community faces.

A program for prevention and mitigation of emergencies and disasters.

Identification of those responsible for all aspects of comprehensiveemergency management and planning for prevention, response andrecovery.

Acceptance of support roles and responsibilities.

Identification of those responsible for controlling and coordinatingemergency operations.

Cooperation between emergency services and others, and acceptance oftheir roles in emergency management.

A coordinated approach to the use of all resources, arrangements to

enable communities to recover from emergencies and disasters.


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KEY EMERGENCY MANAGEMENT AUTHORITIES

National

22. The peak national emergency management policy body is the National

Emergency Management Committee (NEMC) chaired by the Director General,Emergency Management Australia, and comprising the Chairpersons andExecutive Officers of the peak State or Territory emergency managementorganisations and representatives from other appropriate peak Commonwealthand national bodies.

Commonwealth

23. The role of the Commonwealth Government is essentially to assist States andTerritories with developing their emergency management capabilities.Emergency Management Australia (EMA) is responsible for the day-to-daymanagement of this Commonwealth function. EMA coordinates CommonwealthGovernment physical disaster assistance to States and Territories, and tooverseas countries on behalf of the Australian Agency for InternationalDevelopment (AusAID). The Commonwealth also provides financial assistancethrough the Natural Disaster Relief Arrangements which are administered bythe Department of Finance and Administration.

State and Territory

24. States and Territories have primary responsibility for the protection and

preservation of the lives and property of their citizens through: legislative and regulatory arrangements within which the community and

various agencies operate;

provision of police, fire, ambulance, emergency services, and healthservices; and

government and statutory agencies which provide services to thecommunity.

PRINCIPLEUnder the Commonwealth of Australia Constitution Act the

management of disasters or a major incident is a State/Territoryresponsibility.

25. Each State or Territory has established a peak emergency managementorganisation, comprising senior members of appropriate Government agenciesand other organisations, to consider emergency and disaster managementmatters. While the names and functions of these committees vary from State toState, they are responsible for ensuring that plans and arrangements are inplace for dealing with emergencies and disasters.


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Local Government

26. Local governments play a major role in the emergency managementpartnership by providing a variety of services such as public works, health,welfare and other functions which are required on a daily basis, and particularlywhen the community is affected by emergencies and disasters. Whilearrangements differ between States and Territories, committees atdistrict/regional and/or local levels are responsible for aspects of emergencymanagement within their jurisdiction.

Other Organisations and Individuals

27. Many private sector, voluntary and community organisations, professionaldisciplines and individuals also contribute to planning and management ofemergencies and disasters, and play significant roles in prevention,preparedness, response and recovery.

DISASTER MEDICINE AND HEALTH POLICY-MAKING28. The Australian Medical Disaster Coordination Group (AMDCG) is the peak

body for the development of national policy on disaster medicine. The AMDCGreports to the Australian Health Ministers Advisory Council (AHMAC) andcomprises representatives from the State and Territory health authorities, theCommonwealth Department of Health and Aged Care, EmergencyManagement Australia and the Department of Defence.

29. At the Commonwealth level primary responsibility for disaster medicine andhealth policy resides with the Department of Health and Aged Care, and withrespective health and ambulance authorities at the State and Territory level.

Policy is implemented by all levels of GovernmentCommonwealth,State/Territory and Local.

EMERGENCY MANAGEMENT OPERATIONAL AGENCIES

Commonwealth

30. During disasters, EMA coordinates the provision of Commonwealth physicalassistance to States and Territories from the National Emergency ManagementCoordination Centre (NEMCC) at EMAs Canberra Office. Through a network ofEmergency Management Liaison Officers (EMLOs), the NEMCC has call onCommonwealth resources and such commercial assistance as may be deemed

necessary. Assistance coordinated by EMA is usually provided at no cost toStates or Territories.

Commonwealth Assistance

31. There is an established procedure for requesting assistance from theCommonwealth. All States and Territories have a nominated officer or officerswho are authorised to request Commonwealth assistance in the event thatState/Territory or commercial resources cannot meet the requirement.Nominated officers are as follows:

QldExecutive Officer, Central Control Group, State Counter Disaster

Organisation


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NSWState Emergency Operations Controller

ACTExecutive Officer, ACT Emergency Management Committee

VicState Emergency Response Coordinator

TasExecutive Officer, State Disaster Committee and Executive SAState Coordinator, State Disaster Committee

WAState Emergency Coordinator

NTExecutive Officer, Counter Disaster Council

All State and Territory requests for assistance must only be made via thenominated officer.

32. Personnel who are involved in developing a request for assistance from theCommonwealth must:

provide a brief description of the requested resources, the need andassociated tasks;

provide a reason for the request and reasons why the requirement cannotbe met from within State/Territory resources (government, commercial orother);

the request must be couched in the form of the problem. Do not specifythe solution other than in very general terms;

when transport is required, identify weight and dimensions and any specialstorage/handling requirements;

nominate the personnel skills required, not the individuals;

in the case of personnel and equipment, indicate the duration of therequirement;

provide details of when and where the resources are required;

provide full details of the delivery point, contact officer/s at both the Statelevel and the receiving area, plus telephone and facsimile numbers (whereavailable); and

provide any general comments that may contribute to the most timely andeffective response to the request.

33. This procedure does not preclude liaison between agencies during disasters,but the established State/Territory/Commonwealth operational agencies shouldbe kept fully informed.


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State and Territory

34. Each State and Territory has an operational authority responsible for theactivation of appropriate disaster plans and a State Emergency OperationsCentre (or equivalent) capable of command/control/coordination of all resourcesrequired to deal with the disaster at the State/Territory level.

35. The health authority in each State/Territory is responsible for coordinating thehealth function. The authority may task, activate and/or finance Government,private and non-Government Agencies to provide health services.

36. Health personnel should check with the relevant authorities for advice onState/Territory and local administrative and management arrangements.

SUMMARY

37. An understanding of the Australian emergency management framework and itsassociated concepts is important in helping to place the management of thehealth effects of disasters in context.

38. Australian emergency and disaster management arrangements are based onthe following concepts:



The All Hazards Approach


39. Emergency Risk Management is a relatively new concept also gainingacceptance among the Australian disaster management community.

40. There are established arrangements incorporating Commonwealth,State/Territory and local government to provide a coordinated response todisasters within Australia.

REFERENCES

41. References used in this Chapter are as follows:

Emergency Management Australia: Australian Counter-DisasterHandbookVolume 1: Commonwealth Counter-Disaster Conceptsand Principles, Second Edition 1993.

Emergency Management Australia: Australian Counter-DisasterHandbookVolume 2: Australian Emergency ManagementArrangements, Fifth Edition 1996.

Emergency Management Australia: Australian Emergency ManualsSeries, Part I Manual 3Australian Emergency ManagementGlossary, 1998.

Natural Disasters Organisation: Australian Emergency Manual

Community Emergency Planning Guide, Second Edition 1992.


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Standards Australia: Australian/New Zealand Standard(AS/NZS 4360:1995) Risk Management, Standards Australia, New SouthWales, 1995.

EMA Website: http://www.ema.gov.au


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CHAPTER 3

PLANNING

INTRODUCTION

1. The purpose of this chapter is to provide advice on key points in thedevelopment of comprehensive and integrated plans for managing healtheffects of disasters.

WHY PLAN?

2. The economic and social effects of major emergencies and disasters includedestruction of property, dislocation of communities, loss of life, numerous

injuries and years of mental trauma.

3. Coping with hazards gives us a reason and focus for planning. If hazards,natural or technological did not threaten, there would be no reason to plan, asnormal daily health and medical arrangements within communities in particular,are usually sufficient to cope with the day to day issues. All communities facehazards of different types and severity. Planning processes will reveal hazards,identify vulnerable aspects of the community and determine strategies toenable communities to manage the risks associated with the interaction ofhazards and vulnerabilities.

PLANNING MANAGEMENT AND RESPONSIBILITIES

4. An agreed management structure should apply to all aspects (incorporatingprevention, preparedness, response and recovery) at all levels of emergencymanagement planning (Commonwealth, State/Territory, district/region, local,organisation, community).

5. Representative planning committees are essential to emergency planning toensure that all aspects of managing disasters are covered in the planningprocess and to gain the commitment of key people and organisations.Emergency management planning committees need to determine which

specialist functions are necessary for effective management of emergency anddisaster risks. These functions may include public safety, health,communications, rescue, welfare (which usually includes catering, clothing,housing and personal support services), transport, engineering and agriculture.

6. It may be necessary to form functional planning sub-committees responsible tothe main planning committee to prepare and maintain supporting plans coveringessential functions. Functional sub-committees are usually established at State,district and (where practicable) local levels. A representative of each functionalsub-committee should be a member of the main planning committee.


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HIERARCHY OF PLANS

7. A critical concept in emergency management, particularly in response andrecovery planning, is the control of escalating operations. Initial operationalactivity is at the local level. More resources may be called in gradually from the

regional, state or national level, as required, to supplement resources at thelower levels.

8. Therefore, compatibility between plans at the different levels is required. Ahierarchy of emergency management plans exists whereby plans at lowerlevels dovetail into plans at the next highest level. Command and controlarrangements, as well as the roles and responsibilities described in a plan,must be compatible with other plans to which it relates.

EMERGENCY AND DISASTER PLANNING

9. Emergency planning refers to the analytical and consultative process whichenables governments, organisations and communities to manage risks from thevarious hazards which they face. Emergency management arrangements andrelated strategies should flow from this process.

10. The interactive process of planning should result in:

assessment of a communitys hazards, vulnerabilities, and risks ofdisasters and their likely effects;

strategies encompassing prevention, preparedness, response and

recovery;

an understanding of other agencies roles and responsibilities;

strengthening of emergency networks; and

a comprehensive written plan.

PRINCIPLEA communitys ability to manage emergencies and disasters

effectively will depend on whether it has prepared plans

encompassing prevention, preparedness, response andrecovery strategies.


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THE PLANNING PROCESS

11. There are different ways to prepare emergency management plans. TheAustralian Emergency Manual (AEM)Community Emergency Planning Guideprovides a suggested structure for the planning process, from which all relatedprograms, strategies and arrangements should flow. The important commonelements are provided below:

Determine Authority to PlanThe authority to plan is established eitherunder legislation, by government direction, or by community agreement.

Establish Planning CommitteeThe formation of State, regional/district,and local planning committees encourages involvement of all appropriateorganisations. The planning committee should contain representatives of

all organisations, which are involved in emergency management at thatparticular level. In health planning, the committee should comprise


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representatives of all components of the health system, including publichealth, mental health, ambulance, hospitals (both private and public), andmedical practitioners, and links identified with other emergencymanagement planning committees, such as police, SES, fire and rescue,and local government.

Conduct Risk Assessment (incorporating hazard and vulnerabilityanalyses and epidemiology)Risk assessments describe in detail thehazards that may impact on the community in question, the vulnerabilitiesof the community to these hazards and the built, natural and socialenvironments which surround the interaction between hazards andcommunities. Through this process the scope and priorities for planning,including health, are identified. Disaster epidemiology provides healthplanners with information on the health problems associated withdisasters. This is described in further detail later in this Chapter.

Set Planning ObjectivesPlanning objectives are based on the resultsof analyses and detail the required emergency management strategies.Health plans will contain the strategies to minimise the negative healtheffects of emergencies and disasters.

Apply Management StructureManagement arrangements aredetermined by planning committees, in accordance with legislation,government direction, or by other authorities. Health plans andmanagement arrangement should integrate with the overall emergencymanagement plans as well as higher level health plans.

Determine ResponsibilitiesAgreement on the roles andresponsibilities of participating organisations must be reached. In healthterms, for example, this may include responsibilities of health personnel(eg liaison officers), health facilities (eg medical teams) and volunteerorganisations (eg first aid responders). Once roles and responsibilities areagreed, there will be a requirement to ensure that individuals arecompetent to perform effectively, and if not, appropriate training should beprovided.

Analyse ResourcesA resource analysis is undertaken to identify theresources required for effective emergency management, the resourcescurrently available within the community, and any shortfalls (andsurpluses) that exist. Arrangements to overcome shortfalls should bemade. Access to further resources may be covered in higher level plans orthrough mutual aid arrangements.

Develop Emergency Management Arrangements and SystemsTheplanning committee identifies and develops specific managementarrangements and strategies for prevention, preparedness, response andrecovery. The group may also identify other emergency managementissues and refer these to appropriate agencies for attention. There is alsoa requirement to design emergency management systems, which mayinclude: communications, public education, emergency operations centremanagement, effective liaison, information management, publicinformation, resource management, training and performance evaluation,


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and financial management. Health emergency managementarrangements should address public and mental health requirements, aswell as the acute medical response.

Document the PlanDetailed documentation begins as soon as the

planning process commences. Documents resulting from the planningprocess may include the results of risk analyses, the main plan, theprevention, response and recovery plans, functional (including health) andspecial plans; and emergency service procedures. Special health plansmay include hospital plans and evacuation and care arrangements forvulnerable persons and health facilities. The final agreed documentsshould be printed and distributed to users according to their needs.

Test the PlanOnce documentation is complete, the operational aspectsof the plan should be tested (exercised) to measure the extent to whichthe planning objectives have been achieved. Further details on conducting

exercises are contained in Chapter 20. Activate the PlanEmergency management plans must cover in detail

the process for the activation of plans and other arrangements. Activationof a functional plan (for example, health) will usually occur afterconference and agreement between the appropriate functional controllerand the operational authority at that particular level. Plans will normally beactivated in stages, although timing may be condensed in somecircumstances.

Review PlansIt is important plans are regularly reviewed and updated.Review of plans may result from operations, exercises, a prescribedprogram for reviewers, or significant changes to hazards, the community,or the environment. Planning is a continuous process. The written plan isa living document, constantly being reviewed and updated.

PRINCIPLE

Best practice requires preparation, practising and review of disasterplans.

12. Operational plans should include:

authority signed jointly by participating organisations;

aim and scope of plan;

procedures to ensure timely activation and the phases of activation;

control and command procedures;

arrangements for the coordination of support;

the location of the Control Centre, with an alternative;

information and communication management strategies;

dates for the review and exercise of the plan;


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date of issue on every page;

distribution of the plan; and

annexes which include specific operational procedures, chain ofcommand, duty statements, personnel and means of contact, resources

and debrief procedures.

PRINCIPLEThe process of planning is more important than the written

documents that result.

CONDUCT RISK ASSESSMENT

13. Disaster risks differ between communities and within communities. Disastermanagers should conduct risk assessments to identify the hazards which mayaffect a community, the parts of the community which are vulnerable to them,and any likely effects resulting from their interaction. Disaster effects couldinclude: deaths, injuries and disease, food shortages, social disruption,infrastructure damage and loss of services, damage to private property,economic disruption and environmental damage.

14. Managers must then determine how these risks should be managed. The rangeof management options include prevention, preparedness, response andrecovery strategies. Health planners should identify the health implicationsassociated with these risks and determine how they should be managed mosteffectively.

15. The effects of disasters is determined by a number of factors, including:

the type, frequency and intensity of the hazard;

the predictability of the hazard and speed of onset, including the warningperiod, if any;

the duration and area of impact;

the location of the disaster area;

the implementation of prevention measures which build community andindividual resilience;

preparedness of the community including individual and communitypreparedness measures, and the preparation of response and recoveryplans;

the quantity and quality of resources available, including equipment andpersonnel; and

access to other sources of assistance.

Hazard Analysis

16. A hazard can be defined as a source of potential harm or a situation with apotential to cause loss; a potential or existing condition that may cause harm topeople or damage to property or the environment; an intrinsic capacity


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associated with an agent or process capable of causing harm. Hazards mayresult from either extremes of nature, or technological causes. They vary intheir intensity, frequency, area affected, warning time, and how they can bemanaged. Hazards only become disasters when they impact on vulnerablecommunities. Hazards can be classified into the following categories:

Natural/Biophysicaleg cyclones, earthquakes, fires, floods, landslides.

Technological/Sociotechnicaleg chemical, transport (aircraft, motorvehicle, shipping, rail), terrorist-instigated events.

Vulnerability Analysis

17. Vulnerability can be defined as the degree of susceptibility and resilience of thecommunity and environment to hazards. Information is gathered oncharacteristics which describe the vulnerability of the community to hazards.Characteristics include the demographic profile, cultural attitudes, high riskgroups, economic status, quality of infrastructure, community services and

resources, land management, environmental factors. Vulnerable groups in thecommunity, such as the elderly, children, the poor and caravan park residentsmay be disproportionately affected by disasters. This is for a number ofreasons, including building standards, mobility, disabilities, educational levels,access to medical care and nutritional status.

Disaster Epidemiology

18. Disaster epidemiology can be defined as the discipline that studies theinfluence of such factors as lifestyle, biological constitution and other personalor social determinants on the incidence and distribution of disease as itconcerns disasters.

19. Disaster epidemiology can be used to measure and describe the adversehealth effects of disasters, and the factors that contribute to these effects. It hasbeen well recognised that different types of disasters are associated withdifferent patterns of illness and disease. Similarly, specific medical and healthproblems tend to occur at different times after the disasters impact.

20. The objectives of disaster epidemiology are to:

assess the needs of disaster-affected populations;

match needs to available resources;

prevent adverse health effects;

evaluate program effectiveness (such as immunisation programs); and

permit more effective planning.

21. Disaster epidemiology may involve:

disease surveillance;

evaluations of the public health impact of a disaster;

evaluations of the natural history of the disasters acute health effects;

analytic studies of risk factors for adverse health effects;


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clinical investigations of the efficacy and effectiveness of particularapproaches to diagnosis and treatment;

population-based studies of long-term health effects;

studies of the psychosocial impact of a disaster; and

evaluations of the effectiveness of various types of assistance.

22. Tools utilised may include rapid field assessments of health effects, reportingfrom health facilities and practitioners, environmental health surveys, diseasesurveillance and nutritional assessments.

23. A table of disasters and their health effects appears at Annex A to this Chapter.

Implications for Health Planners

24. Health planners at National, State, local or health facility levels can apply

disaster epidemiology in all phases of disaster management (prevention,preparedness, response and recovery) to manage the health effects ofdisasters. Effective management of health aspects of disasters mustincorporate a total health approach, involving the components of:

public/environmental health;

acute medical care;

ambulance services;

first aid; and

mental health.

25. Effective health management depends on anticipating health problems, anddelivering the appropriate interventions to minimise or prevent their effects. Thiswill enable health planners to manage limited health resources effectively.

26. Epidemiology can assist health planners by identifying those groups more atrisk from specific types of disasters, and the types and patterns of injury andillness resulting. For example, traumatic injuries occur mainly at the time ofimpact, whereas increased disease transmission takes longer to develop, as dothe mental health consequences.

27. Up to 80 per cent of persons injured in most disasters usually require only

routine treatment for superficial injuries such as bruising and abrasions. Up to20 per cent are likely to suffer from a single major injury such as a fracture.Frequently, less than 10 per cent are severely injured. Most of the seriousinjuries occur as an immediate outcome of the impact of the disaster anddemand immediate attention.

HEALTH RESPONSE PLANS

28. Health and Medical Functional Plans, developed by the Health and MedicalPlanning Committees utilise the total medical and health resources in the area.They must be integrated with other disaster response agencies and aredesigned to provide:

command, control and co-ordination of resources;


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appropriate pre-hospital medical and health management for casualties;

transportation of casualties to appropriate hospitals for definitive treatmentand care;

public health advice and warnings to responders and the community;

psychological and counselling services for disaster affected persons;

on-going medical and health services required during the recovery periodto preserve the general health of the community; and

provision for persons with a disability or other form of special need,including cultural considerations.

SPECIAL CONSIDERATIONS IN HEALTH RESPONSE PLANNING

Time Delay to Resuscitation

29. Mortality from trauma typically occurs in one of three distinguishable timeperiods. These are:

seconds to minutes (usually from unsurvivable head or major vesseldamage);

one to two hours (usually from major chest, head or abdominal injuries,and/or major blood loss); and

days to weeks (usually from brain death, sepsis and organ failure).Accurate diagnosis and resuscitation in the first hour may significantlyreduce this second peak of mortality.

Time Delay to Surgery

30. In addition, data from military studies suggests that for battle casualties whorequire surgical intervention, there is a dramatic increase in the mortality ratefor those who remain untreated for three hours after wounding. After six hoursthere is a further dramatic increase in eventual mortality and morbidity.Accordingly, for serious casualties, initial wound surgery should be performedas soon as possible, but certainly within the three hour limit.


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Initial Phase

31. This involves deployment of (probably) local resources to provide immediateattention and identification of the health and medical problems. In the initial

phase the requirement is for appropriately trained medical personnel to travel tothe site and conduct medical reconnaissance, initial triage and resuscitation.

Follow-up Phase

32. This involves a designated medical services coordinator arranging moredefinitive medical care which, in some circumstances, could involve theacquisition or employment of additional regional, State or National medicalresources. In the follow-up phase the requirement is for:

medically trained persons to travel to the site and treat casualties in placeand/or stabilise casualties in preparation for evacuation;

evacuation of casualties for treatment elsewhere; and

public health support.

33. Some of the special considerations which need to be addressed include theprovision for:

care for people with disabilities;

care for the detainees in correctional institutions;

response for the remote area occurrence; and

special planning involvement for major events.

Care for People with Disabilities

34. It is essential that each community is aware of persons with some form ofdisability who may, in times of major incidents or disasters, need to havespecial provisions made in respect of evacuations, transport and continuingcare and treatment. Health and community service groups who deal withpersons with disabilities on a day to day basis need to be involved in theplanning process as they are probably the best suited to identify such personsand to provide centralised records which can be provided to various emergencyservice responders. Where such persons are housed in special accommodation

or institutions, special plans and arrangements will be in place and need to beconsidered by the community and response agencies for response andrecovery purposes in the main plan.

Detainees in Custodial/Correctional Institutions

35. The provision of services to persons from these institutions may involve non-medical personnel such as correctional service officers and the police. In suchcases additional care may be needed for the security and management ofhealth personnel and/or equipment to prevent, for example, a possible hostagesituation involving health personnel.


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Remote Area Planning

36. Whilst clinical management principles remain the same regardless of situations,planning for the remote area disaster will require that the key factors of time

delay period and casualty deterioration rate are adequately addressed. Theeffect of an obvious range of difficulties inherent with accessibility, distance orisolation may be minimised with good prior planning and arrangements.

Major Events

37. Major or special events can be a common factor in creating mass casualtysituations. Health professionals from all areas of health, medical andambulance should be actively involved in the planning for such events in anendeavour to prevent mass casualty situations arising or at least be preparedfor their potential occurrence. Reference should be made to Chapter 16MassGatherings, or the Australian Emergency ManualSafe and Healthy Mass

Gatherings: Health and Safety Guidelines for Public Events, recently publishedby Emergency Management Australia.

Common Difficulties in Disaster Response Planning

38. Frequently encountered problems in disaster response planning include thefollowing:

CommunicationCommunication facilities (all forms) are inevitablyoverloaded and information management may be difficult to control orcoordinate.

Knowledgethere tends to be insufficient knowledge or recognition ofavailable on-site resources and services, and specialised alternativeemergency resources are often difficult to identify and mobilise.

Planningthere is often a lack of adequate planning, training andexercising to prepare for the special needs of disasters.

Key Objectivesthe key objectives of counter-disaster plans, includingagency roles, are not clearly defined and understood, often due toagencies having multiple day to day responsibilities.

Coordinationcoordinated response from an area remote from thescene is often difficult as agencies keep information and requests inhouse and the coordination is overlooked at the provider end - inadequatecoordination can result in reaction delays or overload.

Environmentenvironmental factors such as the weather, terrain andnatural resource depreciation often directly impinge upon the responsephase.

Controlcontrol can be difficult when scarce resources are stretched.

Capabilitycapability always seems to fall short of what was expected.

Limited Outlookparochialism hinders a coordinated response.

Basic Necessitiesthe provision of adequate water, food and shelter for

the disaster victims and responders particularly in remote locations.


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Prepared Responsethose persons responding to remote area incidentsmust be physically fit for the task ahead and self sufficient for food,water and the basic essentials for at least the initial period.

SUMMARY

39. The development of comprehensive plans, based on consultation with keyhealth agencies, is crucial in managing the health effects of disasters.

40. Health plans should be integrated with the overall plans of other disastermanagement agencies.

41. Some specific groups or situations require special consideration in healthplanning.

42. Disaster epidemiology should be used during all phases of disastermanagement as it can provide valuable information regarding the adversehealth effects of disasters and the factors that contribute to these effects.

REFERENCES

43. References used in this Chapter are as follows:

Dolan, C., Hazard-Wise, Emergency Management Australia, 1995.

Noji, E.K., The Public Health Consequences Of Disasters, OxfordUniversity Press, 1997.

Pan American Health Organization, A Guide to Emergency HealthManagement After Natural Disaster, 1981.

Royal Australasian College Of Surgeons. Early Management of SevereTrauma.

Santy, M.P. (English translation of article): Bulletin de la SocieteMedico-Chirurgicale, Paris, France, Vol 44, 1918, pages 207214.

Withers, D.J., A Rapid Response Medical Capability for Australia. TheMacedon DigestThe Australian Newsletter of DisasterManagement. Mt. Macedon, Victoria, Volume 6 Number 1, March 1991,pages 810.

Annex:

A. Disasters and their Health Effects


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ANNEXATO

CHAPTER3

DISASTERSANDTHEIRHEALTHEFFECTS

H

azard

EnvironmentalEffects

Deaths

SevereInjuries

Public

HealthConsequences

Po

pulation

Movement/

Ev

acuation

Earthqua

ke

Bu

ildingco

llapse.

Disrup

tion

touti

litysupp

ly.

Heavy

dus

t.

Frequen

tfiresa

nd

chem

ica

lsp

ills

Many

O

verw

he

lming

Lossofu

tilities

hyg

iene,

san

itatio

n

Many

ho

me

less

Rare

Floods

(slow

movin

g)

Ve

hicles

/carava

nsan

d

bu

ildingswashe

daway

Few

F

ew

Wa

tersupp

ly,

hyg

iene,

san

itatio

n

Riskofw

atervec

tor-

borne

disease

Many

ho

me

less

Common

Fires

(bus

hor

structura

l)

Devas

tationofc

rops,

fores

ts,

pas

tures,

struc

tures.

Smo

ke

damage

.

Toxicgases.

Few

F

ew

Disposa

lo

flives

toc

k.

Common

Cyc

lones

(inclu

des

po

tentia

ls

torm

surge

an

dflas

h

flooding

)

Damage

tocom

mun

ity

infras

truc

ture,r

es

idences,

crops.

Winds

few

Flas

hfloo

ding

/

surgemany

W

indsmo

dera

te

(

trauma

from

fly

ing

d

ebris

)

F

las

hfloo

ding

/

s

urge

few

Wa

tersupp

ly,

hyg

iene,

san

itatio

n

Riskofw

atervec

tor-

borne

disease

Many

ho

me

less

Common

Chem

ica

l(direc

t

sp

illo

rleac

hing

intoso

ilan

d

wa

ter

table)

Con

tam

ina

tiono

fwa

ter

table/so

ilmayoccur.

Fires.

Airpo

llution.

Effec

tdepen

dso

ntox

icity,rou

teo

f

exposurean

ddo

es

forworkers,

rescuers,

adjace

ntan

ddistan

t

commun

ities.Cr

osscon

tam

ina

tion.

Morb

iditymay

be

chron

ic

Deconta

mina

tiono

fcasua

lties.

Con

tam

ina

tiono

fwa

tersupp

ly.

Long-ter

menvironmen

t/hea

lth

consequ

ences.

Common


48/299

ANNEXATO

CHAPTER3

Terroris

t-

ins

tiga

tedeven

t

(explo

sive,

chem

ica

l,

biolog

ica

l,

radiolog

ica

l

attack

)

Devas

tationofimme

diate

env

ironmen

t

Bu

ildingco

llapse.

Flying

de

bris.

Many

M

any

Res

tora

tiono

fu

tilities.

Deconta

mina

tion.

Rare

(as

req

uire

d)

Trans

port

(from

huma

nerror,

mechan

ica

l

failure

or

terroris

t

ac

tion

)

Disrup

tion

totra

nsport.

Fire

Chem

icalsp

ill

Mu

ltiple

fatalities.

M

any

May

bes

ign

ifican

tmen

talhea

lth

effec

ts

Rare


49/299

CHAPTER 4

PUBLIC HEALTHPREVENTION AND MITIGATION

INTRODUCTION

1. The impact of hazards on communities may be prevented or mitigated by avariety of strategies. These strategies will involve modification of the hazard, ormore often reduction in the vulnerability of a community to hazards.

INTERSECTORAL APPROACH

2. Through epidemiology studies and research, health professionals cancontribute to an inter-sectoral approach to prevention/mitigation. Possible

strategies involving an inter-sectoral approach include: zoning/land use management;

building codes;

building use regulations;

relocation of potential hazards or communities;

safety improvements;

legislation;

public information;

community awareness/indication; and

tax, insurance incentives/disincentives.

MEASURES

3. Prevention or mitigation of natural hazards can occur through a variety ofstructural measures, protective engineering works such as dams, levees, sea

walls, and nonstructural options including land use regulations, zoning laws,building codes, and economic programs (such as tax and insurance incentives)designed to keep vulnerable structures and activities out of the most hazard-prone areas to minimise the likelihood of structural damage. Post disasteractions such as rebuilding damaged structures in hazard-resistant ways orrelocating structures and people are also mitigation strategies due to theirconcerns with the long term reduction of the effects of hazards.


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MITIGATION STRATEGIES

4. Mitigation of technological disasters can range from altering expectations andthe choices of technology to preventing or lessening the consequences of a

hazard, as indicated above.

5. Many aspects of public health contribute to reducing the risks of disaster. Goodhealth status is in itself a protective measure. Mitigation strategies can beidentified by considering the epidemiology of disasters, as well as taking intoaccount characteristics of the community, such as vulnerability.

Prevention strategies also need to be epidemiologically evaluated as to theireffectiveness. Specific health interventions that contribute to prevention /mitigation of disasters may include:

immunisation for appropriate diseases;

chemoprophylaxis as appropriate;

sanitation measures;

personal hygiene;

refuse and hazardous waste disposal;

vermin and vector control;

immigration controls and custom legislation;

education programs;

media campaigns;

public warning notices; and

incident data collection, analysis and dissemination.

SUMMARY

6. Hazard modification and reduction in community vulnerability are key strategies

in the approach to prevention and mitigation.

7. The impact of hazards can be prevented or mitigated through the use ofepidemiological studies and research.

8. Epidemiological evaluation is important in determining the effectiveness of keystrategies


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REFERENCE

9. Reference for this Chapter is as follows:

Emergency Management Australia: Australian CounterDisaster

Handbook Volume 1, Commonwealth CounterDisaster Conceptsand Principles, 1993, ISBN 0 642 19581 1.


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CHAPTER 5

HEALTH RESPONSE AND

DISASTER SITE MANAGEMENTINTRODUCTION

1. The purpose of this chapter is to provide a guide for the efficient managementof health resources in a disaster. This may range from an event where there isa concentration of casualties in a restricted area eg bus crash, to an incidentspread over a wide area which will require multiple field management structureseg earthquake.

2. All health care professionals have a duty to understand the disaster

management arrangements, which will include command, control andcoordination, their roles and those of other involved agencies, thereby ensuringan effective medical response. This will require participation in appropriateeducation programs and regular exercises.

PRINCIPLEEffective management will provide optimal care for the

maximum number of casualties.

MANAGEMENT STRUCTURE

3. In all States and Territories, there is need for a management structure whichencompasses State/Territory and regional levels, within hospitals and at theincident site. Additionally, the mutual aid arrangements betweenStates/Territories should be addressed. Please refer to Chapter Three onPlanning for further information.

COMMAND, CONTROL, COORDINATION AND COMMUNICATION

Introduction

4. Arrangements often referred to as the four Cs, command, control, coordinationand communication are vital to the management of the diverse resources thatwill be involved in the response to any major emergency or disaster.

5. It is important that the response planned and provided from the Health andMedical agencies during disasters are directed in the same manner using thisterminology. This will serve as a medium to enhance or clarify position functionsto other participants where similar roles and functions occur.

6. The widely accepted definitions throughout Australia of the terminology ofCommand, Control and Coordination, are outlined as follows:


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Command

7. Command is the direction of members and resources of an organisation in theperformance of the organisations role and tasks. Authority to command isestablished in legislation or by agreement within an organisation. Commandrelates to organisations and operates vertically within an organisation.

Control

8. Control is the overall direction of emergency management activities in adesignated emergency or disaster situation. Authority for control is establishedin legislation or in an emergency plan, and carries with it the responsibility fortasking and coordinating other organisations in accordance with the needs ofthe situation. Control relates to situations and operates horizontally acrossorganisations.

Coordination

9. Coordination is the bringing together of organisations and resources to ensurean effective emergency management response. It is primarily concerned withthe systematic acquisition and application of resources (organisational,personnel and equipment) in accordance with the requirements imposed by thethreat or impact of an emergency or disaster. Coordination relates primarily toresources and operates vertically within an organisation as a function of theauthority to command, and horizontally, across organisations, as a function ofthe authority to control.

PRINCIPLE

Disasters create the need for coordination between allparticipating agencies. This requires reliable inter-agencycommunication.

Establishing Medical Control

10. In all major emergencies and disasters, establishing control over the situation inthe early part of the response is difficult. The Medical and Health EmergencyPlanning Authorities need to have in place, an organisation, which is wellunderstood by all participants and which provides for a 24-hour appropriatesystem of communicating with, and mobilising, the required medical and healthresponse.

Communication

11. Communication is vital to ensure the two way flow of information and for theexercising of command, control and coordination, and it must be accurate andtimely.

12. The inabil